NURS 309 - Chapter 48 Skin Integrity and Wound Care

After a surgical procedure, the patient experiences thrombocytopenia. For which condition would this postsurgical patient be at risk? Infection Dehiscence Evisceration Hemorrhage

Hemorrhage

Which dressing would the nurse use to protect and absorb moisture when providing care to a patient with a pressure injury? Gauze Adherent film Calcium alginate Hydrogel covered with foam

Hydrogel covered with foam

Which dressing would be inappropriate for intact stage 1 pressure injuries? Select all that apply. One, some, or all responses may be correct. Gauze Transparent Hydrocolloid Composite film Calcium alginate

Gauze Composite film Calcium alginate

Which student nurse statement about assessing dark-skinned patients indicates adequate learning? Select all that apply. One, some, or all responses may be correct. "Cyanosis is easily detected in dark-skinned patients." "Identification of early pressure ulcers may be difficult." "The elbow is a good site for underlying skin color identification." "Hyperpigmentation on the sacrum indicates the patient has cyanosis." "Assessment of skin temperature and edema should be considered a priority." "Assessment of change in tissue consistency in relation to surrounding areas should be a priority."

"Identification of early pressure ulcers may be difficult." "Assessment of skin temperature and edema should be considered a priority." "Assessment of change in tissue consistency in relation to surrounding areas should be a priority."

Which nursing intervention would be appropriate for a patient who is at risk of skin breakdown because of moisture?

Keep the skin dry and free of maceration.

Which size syringe is used for irrigating an open wound?

35 mL

Which statement is true regarding cold application? Cold application causes vasodilation. It reduces blood viscosity. Cold application decreases muscle tension. It increases tissue metabolism

Cold application decreases muscle tension. Cold application decreases muscle tension and helps relieve pain. Heat, not cold, application causes vasodilation, reduced blood viscosity, and increased tissue metabolism because of increase in blood flow.

The removal of devitalized tissue from a wound describes which process? Debridement Pressure reduction Negative pressure wound therapy Sanitization

Debridement

Which condition warrants the use of cold therapy? Direct trauma Rectal surgery Painful hemorrhoids Vaginal inflammation

Direct trauma

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? Binder Ice bag Elastic bandage Absorptive diaper

Ice bag An ice bag helps constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help control bleeding, and can decrease pain where the ice bag is placed. Binders are usually placed around the abdomen to make movement less painful and to provide support. Elastic bandages promote hemostasis and will not help anesthetize the body part. An absorptive diaper is not appropriate in this situation.

Which nursing action would be appropriate when removing tape from the patient's skin during wound care? Select all that apply. One, some, or all responses may be correct. Loosen the ends Pull the tape in the direction of hair growth Use adhesive remover to loosen the tape Apply hard traction to the skin next to the wound Gently pull the outer end perpendicular to the skin surface

Loosen the ends Pull the tape in the direction of hair growth Use adhesive remover to loosen the tape

Which intervention would be most effective for compromised skin integrity? Preventing breakdown Administering medication Implementing wound care Monitoring wound healing

Preventing breakdown

Which characteristic would be the therapeutic benefit of heat application? Select all that apply. One, some, or all responses may be correct. Decreases tissue oxygen needs Promotes the movement of waste products Reduces blood flow to injured body parts Improves blood flow to injured body parts Improves delivery of leukocytes to the wound site

Promotes the movement of waste products Improves blood flow to injured body parts Improves delivery of leukocytes to the wound site

Which pressure injury is expected to heal through granulation and reepithelialization? Stage 1 Stage 2 Stage 4 Unstageable

Stage 4

How much volume of drainage would equal 1 g of dressing? Record your answer using a whole number. ___ mL

1 mL One g of drainage weighed in a dressing equals 1 mL of drainage in volume, and this rule is generally used to determine the quantity of drainage from a wound site.

Which amount of protein per kilogram of body weight a day would the nurse recommend a patient consume to support wound healing? 1.25 to 1.5 g 2 to 3.5 g 3.5 to 4.5 g 5.15 to 6.5 g

1.25 to 1.5 g

Which quantity of vitamin C is recommended for wound healing? Record your answer using a whole number. ______ mg/day

1000 mg/day

Which amount of zinc is recommended for wound healing? 15 to 30 mg 30 to 50 mg 25 to 60 mg 50 to 70 mg

15 to 30 mg

Which amount of retinol equivalents for vitamin A per day would the nurse recommend a patient to consume to support proper wound healing? 1200 to 1400 retinol equivalents per day 1400 to 1500 retinol equivalents per day 1500 to 1600 retinol equivalents per day 1600 to 2000 retinol equivalents per day

1600 to 2000 retinol equivalents per day

While changing the position of a bedridden patient, the nurse observes a reddish-pink wound bed without slough, serosanguineous-filled blisters, and partial loss of dermis thickness. Which pressure injury stage would the nurse infer from these findings? 1 2 3 4

2

How far beyond the wound edges would the nurse extend the sealant when framing the periwound area of a patient? 1 to 2 cm (0.4 to 0.8 inch) 2 to 4 cm (0.8 to 1.6 inches) 2.5 to 5 cm (1 to 2 inches) 4 to 6 cm (1.6 to 2.4 inches)

2.5 to 5 cm (1 to 2 inches) Extending the sealant 2.5 to 5 cm (1 to 2 inches) beyond the wound edges is an accurate nursing action when framing the periwound area with skin sealant. Extending it to 1 to 2 cm (0.4 to 0.8 inch) or 2 to 4 cm (0.8 to 1.6 inches) is not enough. Extending it to 4 to 6 cm (1.6 to 2.4 inches) is more than necessary.

How many kilocalories per kilogram per day would the nurse suggest a patient consume to promote proper wound healing? 15 to 20 20 to 25 25 to 30 30 to 35

30 to 35

Which amount of fluids per kilogram per day would the nurse encourage the patient to drink for proper wound healing? 15 to 20 mL 20 to 25 mL 25 to 30 mL 30 to 35 mL

30 to 35 mL Because adequate hydration is essential for cell functioning and therefore wound healing, the nurse should encourage the patient to drink 30 to 35 mL per kilogram per day. The amounts of 15 to 20 mL, 20 to 25 mL, and 25 to 30 mL are not enough.

Which size tape would the nurse use to stabilize a large dressing? 1.3 cm (0.5 inch) 2.5 cm (1 inch) 5 cm (2 inches) 7.5 cm (3 inches)

7.5 cm (3 inches)

Which patient would be at increased risk of injury from heat and cold applications? Select all that apply. One, some, or all responses may be correct. 75-year-old patient 40-year-old patient with peripheral vascular disease 35-year-old patient with spinal cord injury 50-year-old comatose patient 45-year-old patient with cholecystitis

75-year-old patient 40-year-old patient with peripheral vascular disease 35-year-old patient with spinal cord injury 50-year-old comatose patient Older adults have reduced sensitivity to pain and may not respond well to hot and cold temperatures. Peripheral vascular diseases such as diabetes and arteriosclerosis make the body's extremities less sensitive to temperature and pain stimuli. Spinal cord injuries may cause alterations in nerve pathways and prevent reception of pain and temperature stimuli. A comatose patient may not be able to perceive painful stimuli.

Which prescribe might the nurse anticipate for a patient with new-onset bowel incontinence that is causing compromised skin integrity? A new prescription for a diuretic A change in dietary prescription The implementation of timed voiding The implementation of physical therapy

A change in dietary prescription New-onset bowel incontinence is often treated with a change in diet. A nurse would expect a new prescription for a diuretic if the patient needed increased urine output, but this would not improve bowel incontinence. The implementation of timed voiding is more appropriate for urinary, not bowel, incontinence. The implementation of physical therapy would be appropriate for a patient with impaired mobility, but not bowel incontinence.

Which factor would not place a patient at risk of burns during heat therapy? Very young age Areas of edema Abscessed tooth Peripheral vascular disease

Abscessed tooth

The nurse is providing care to a patient with a pressure injury that is covered in eschar. Which dressing prescription will the nurse use for this patient? None Adherent film Composite film Calcium alginate

Adherent film A pressure injury covered in eschar is an unstageable pressure injury. The nurse would use an adherent film dressing because it will facilitate softening of the eschar to allow for debridement. No dressing is appropriate for an intact stage 1 pressure injury. A composite film dressing is appropriate for a clean stage 2 pressure injury. A calcium alginate dressing is appropriate for a clean stage 3 or stage 4 pressure injury.

Which type of wound drainage is considered sanguineous? Clear, watery plasma Bright red, active bleeding Thick and yellow, green, tan, or brown Pale pink, watery mixture of clear and red fluid

Bright red, active bleeding

Which dressing would the nurse use for a patient with a clean stage 3 pressure injury? None Adherent film Composite film Calcium alginate

Calcium alginate

Which adjuvant treatment is only considered for patients diagnosed with an unstageable pressure injury? Support hydration Nutritional support Surgical consultation for debridement Evaluation of pressure-redistribution needs

Surgical consultation for debridement

After asking for the patient's level of comfort using a scale of 0 to 10, how would the nurse order the steps in assessing the patient's pressure injury?

Correct1.Determine if the patient has any allergies to topical agents. Correct2.Review the order for topical agents or dressing and location. Correct3.Describe the procedure to the patient, and remove the dressing. Correct4.Note the color and percentage of tissue type present in the wound base. Correct5.Measure the width and length of the injury. Correct6.Measure the depth of undermining by using a cotton-tipped applicator. Correct7.Inspect the periwound skin, checking for maceration, redness, or any denuded areas. Correct8.Remove gloves and perform hand hygiene. Correct9.Review the medical record to assess for any significant weight loss.

Which intervention would not be necessary for a patient who has impaired skin integrity related to limited mobility? Demonstrate correct repositioning techniques. Apply dressings to support moist wound healing. Perform an ongoing wound and risk assessment. Apply a moisture barrier to the area at least 3 times daily.

Demonstrate correct repositioning techniques. Demonstrating correct repositioning techniques is an intervention for a patient who has impaired physical mobility related to incisional pain, not a patient who has impaired skin integrity. Applying dressings to support moist wound healing, performing an ongoing wound and risk assessment, and applying a moisture barrier to the area at least 3 times daily are appropriate interventions for a patient who has impaired skin integrity related to limited mobility.

Of which advantage would a moist application be in wound healing? Does not promote sweating Does not cause skin maceration Retains temperature longer Less risk of burns to the skin than dry applications

Does not promote sweating

Which option describes a hydrocolloid dressing? Seaweed derivative that is highly absorptive Premoistened gauze placed over a granulating wound Debriding enzyme that is used to remove necrotic tissue Dressing that forms a gel that interacts with the wound surface

Dressing that forms a gel that interacts with the wound surface. A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Calcium alginate dressings are made from a seaweed derivative and are highly absorbent. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing. Gauze is usually saturated with saline and used to clean or pack a wound. Examples of debriding enzyme preparations are Dakin's Solution and sterile maggots.

Which nursing action would be a teaching strategy for patients and families who will be working with a pressure-redistribution surface? Select all that apply. One, some, or all responses may be correct. Explaining the reasons for the prescription Teaching common errors associated with the prescription Noting the minimum layers of linen to be used with the prescription Asking the patients and caregivers to discuss possible sensations associated with the prescription Requesting a return demonstration of turning and repositioning techniques with the prescription

Explaining the reasons for the prescription Teaching common errors associated with the prescription Noting the minimum layers of linen to be used with the prescription

Which piece of knowledge is not required for assessing a patient's risk of developing pressure injuries? Pathogenesis of pressure injuries Factors contributing to pressure injury formation Factors contributing to wound healing Factors contributing to inflammation and infection

Factors contributing to inflammation and infection

Which statement is true regarding sutures? Fine sutures cause minimal tissue injury. Deep sutures are composed of nonabsorbable material. Continuous sutures are least likely to cause inflammation. Retention sutures are placed more superficially than skin sutures

Fine sutures cause minimal tissue injury. The finer the sutures, the more minimal the injury to the tissue will be. Deep sutures are composed of an absorbable, not nonabsorbable, material that disappears over time. All sutures are foreign bodies, and therefore they can all cause local inflammation. Retention sutures are placed more deeply than skin sutures.

Which factor is an indication of healing of a surgical incision? Select all that apply. One, some, or all responses may be correct. Heals by epithelialization Lacks wound contraction Clean and intact wound edges Lacks granulation tissue formation Heals quickly with minimal scar formation

Heals by epithelialization Clean and intact wound edges Heals quickly with minimal scar formation

Which dressing would the nurse use to protect and absorb moisture when providing care to a patient with a pressure injury? Gauze Adherent film Calcium alginate Hydrogel covered with foam

Hydrogel covered with foam Hydrogel covered with foam is appropriate for a pressure injury that requires protection and absorption of moisture. A gauze dressing is often used for a clean stage 2 or 4 pressure injury. Adherent film dressings are appropriate for unstageable pressure injuries, and calcium alginate dressings are used when the pressure injury is producing significant exudate.

Which step is a component of the planning phase for a patient who has impaired skin integrity? Involve the patient and family in choosing interventions. Apply standards of practice outlining expected outcomes. Examine the patient's skin for impairment of skin integrity. Ask the patient for his or her perception of skin integrity after the intervention.

Involve the patient and family in choosing interventions.

Which intervention is part of the Nursing Interventions Classification (NIC) for wound care? Repositioning the patient every 90 minutes Irrigating the wound with a saline solution 2 times per day Avoiding the use of massage around the open area Elevating the head of the patient's bed to no more than 30 degrees

Irrigating the wound with a saline solution 2 times per day Irrigating the wound with a saline solution 2 times per day is an intervention that supports the wound care NIC. Repositioning the patient every 90 minutes, avoiding the use of massage around the open area, and elevating the head of the patient's bed to no more than 30 degrees are interventions that are part of the pressure management NIC.

The nurse is caring for a patient who is diagnosed with venous stasis pressure injuries. Which support surface would the nurse anticipate for this patient? Low-air-loss bed Nonpowered bed Lateral rotation Air-fluidized bed

Lateral rotation

Which action would be inappropriate for maintaining an airtight seal in negative-pressure wound therapy? Avoiding adhesive removers Moistening the periwound area thoroughly Framing the periwound area with skin sealant Filling uneven skin surfaces with a skin-barrier product

Moistening the periwound area thoroughly

The health care provider prescribes cold compressions for a patient with a sprain injury in the spinal area. Which assessment finding by the nurse would be a contraindication for cold therapy? Select all that apply. One, some, or all responses may be correct. Neuropathy Site edema Shivering Cardiovascular problems Altered level of consciousness

Neuropathy Site edema Shivering

Which nursing intervention would be appropriate for a patient who is at risk of infection because of a surgical incision at the right hip? Applying moisture barrier cream Obtaining a wound culture as needed Providing analgesics before wound care Using correct repositioning techniques

Obtaining a wound culture as needed

Which intervention would the nurse plan for a patient who has a sacral pressure injury? Apply a moisture barrier to the wound at least twice daily. Administer an analgesic 15 minutes before repositioning and wound care. When the patient is lying down, position him or her in a 45-degree lateral position. Pack open areas of the wound with gauze moistened with an antibiotic solution.

Pack open areas of the wound with gauze moistened with an antibiotic solution. For a patient who has a sacral pressure injury, the nurse will plan to pack the open areas of the wound with gauze moistened with an antibiotic solution. The nurse should apply a moisture barrier to the area at least 3 times daily; twice a day is not enough. Administering analgesics 15 minutes before repositioning and wound care does not allow enough time for pain relief; they should be provided 30 minutes ahead of time. When the patient is lying down, he or she should be positioned in a 30-degree, not 45-degree, lateral position.

Which nursing action is appropriate when providing care to a patient who has intact skin but is at high risk of impaired skin integrity of the heels? Avoid prolonged elevation of the head of the bed. Order a standard hospital foam mattress. Consider an alternating pressure support surface. Place a pillow under the calves.

Place a pillow under the calves. The nursing action that is appropriate for a patient who has intact skin but is at high risk of impaired skin integrity of the heels is to place a pillow under the calves to decrease the risk of heel breakdown. Avoiding prolonged elevation of the head of the bed is appropriate for a high-risk patient who already has a pressure injury. Ordering a standard hospital foam mattress is appropriate for a high-risk patient who is not at risk of impaired skin integrity. Considering an alternating pressure support surface is appropriate for a patient who is already diagnosed with a pressure injury.

Which nursing intervention is appropriate for a patient who is at risk of skin breakdown because of decreased sensory perception? Keep the skin dry and free of maceration. Provide a pressure-redistribution surface. Consult a dietitian for nutritional assessment. Provide a trapeze to facilitate movement in bed

Provide a pressure-redistribution surface.

A patient's wound drainage appears thick and yellow. Which type of drainage is this considered? Serous Purulent Sanguineous Serosanguineous

Purulent

Which option is an indication for a binder to be placed around a surgical patient with a new abdominal wound? Collection of wound drainage Reduction of abdominal swelling Reduction of stress on the abdominal incision Stimulation of peristalsis (return of bowel function) from direct pressure

Reduction of stress on the abdominal incision

Which dressing would be inappropriate for a patient with a clean stage 2 pressure injury? Silver Hydrogel Silicone Hydrocolloid

Silver

How is the nursing care for a patient who has a stage 4 pressure injury different from that for a patient who has a stage 1 pressure injury? Stage 4 requires keeping the patient out of a slouched position. Stage 4 requires the use of a low-air-loss, alternating pressure, or air-fluidized support surface. Stage 4 requires keeping the patient out of a prolonged head-of-bed elevation position. Stage 4 requires consulting a seating specialist for the appropriate seating surface for the patient

Stage 4 requires the use of a low-air-loss, alternating pressure, or air-fluidized support surface. For patients who have stage 4 pressure injury, special support surfaces such as low-air-loss, alternating pressure, and air-fluidized surfaces are indicated; but for patients with stage 1 pressure injuries, higher-specification foam or a similar nonpowered redistribution support surface is used. Both stages require keeping the patient out of a slouched position or prolonged head-of-bed elevation position. Both stages require consulting a seating specialist for the appropriate seating surface for the patient.

A patient has come to the clinic after sustaining an abrasion. Which characteristic of this wound type would the nurse likely find upon assessment? Select all that apply. One, some, or all responses may be correct. Superficial Considered a partial-thickness wound Weepy Bleeds profusely Associated with the risk of internal bleeding and infection

Superficial Considered a partial-thickness wound Weepy

The nurse instructs the patient on how to use ice bags correctly. Arrange the steps in the proper order.

The ice bag should be filled with water and closed with the cap. It should then be inverted to check for leaks. The water should be poured out and the bag filled with ice. The ice should fill only two-thirds of the bag, so that the bag can mold over the body part. Excess air may interfere with conduction, so the air should be expelled before securing the cap. The extra moisture on the bag should be wiped off, and the bag should be covered with a flannel cover, towel, or pillowcase. The bag should then be applied on the body part for 30 minutes.

Which nursing action would be appropriate when providing care to a patient who exhibits no risk of skin breakdown? Using a standard surface Placing a pillow under the calves Utilizing an active support surface Applying a pressure-redistribution seat cushion

Using a standard surface

The absence of adequate amounts of which nutrient in the diet may impair inflammatory response in wound healing? Zinc Proteins Vitamin A Vitamin C

Vitamin A

Which nutrient helps healing by promoting epithelialization, wound closure, inflammatory response, and angiogenesis? Zinc Protein Vitamin C Vitamin A

Vitamin A